Two patients seen back to back.
The first was a teenager with two days of belly pain, fever, and vomiting with marked tenderness over the right lower part of his abdomen. I knew he had appendicitis, the nurses knew it, his dad knew it, the housekeepers knew it, everyone and their dog said appendicitis final answer. The surgeon still wanted a scan first since it was the middle of the night and all, and it shockingly came back showing appendicitis.
The second was a college-aged girl with three hours of belly pain and vomiting. Her belly was just sort of mildly tender everywhere, not in any one particular spot. ”You probably have early gastroenteritis, we’ll give you some fluids and zofran and run some tests.” An hour later her white count came back at 20 and I dunno maybe it’s still gastroenteritis but 20 is awfully high so I went to see her again.
She doesn’t feel any better after her fluids which is kind of weird for gastroenteritis and maybe it hurts a little more in her right lower quadrant although maybe I’m just imagining it’s so. Her whole presentation has just been “off” for gastroenteritis and super-early appendicitis is rapidly climbing the differential.
I think about sending her to the scanner, but then I pause. What do I really know, I think. I’m just a stoopid ER doctor, jack of all trades, master of none. Who am I to make this kind of decision? Maybe I should wait for DB to put his multispeciality panel together to tell me what to do.
But then an epiphany. I specialize in emergency medicine. No one sees more appendicitis vs. gastroenteritis than me. No one is more qualified than me, the emergency room doctor, to decide what tests the emergency room patients need. I actually did an entire residency in emergency medicine, believe it or not, learning this kind of stuff. I work exclusively in an emergency room, shocker, continuing to hone my skills. And when some random arrogant internist suggests that other non-emergency doctors should get together to teach us how to do our jobs, I shake my head and smile and wish I could watch them flail about trying to do my job, just as I would if I tried to do theirs.
The scan came back showing “likely early appendicitis.” I examined her yet again and she now had clear localization to the right lower quadrant. Lucky for me it was positive I thought, at least now I won’t get dinged for overtesting.
January 14, 2009 at 4:32 am
In both cases, I would probably have started with an ultrasound. In the first case it would probably have confirmed the diagnosis. In the second case perhaps ultrasound wouldn’t have been conclusive but then you can always wait and see for a few more hours until the symptoms become clear.
January 14, 2009 at 8:14 am
Have you ever heard of anyone getting dinged for overtesting? I haven’t.
I’ve seen quite a few scrapes and gouges from undertesting though, even a totalled career or two.
January 14, 2009 at 1:47 pm
Problems with ultrasound:
1. It’s 3am, I have to wake up the on-call radiologist and ask him to come in to do the ultrasound (they do these themselves instead of the techs).
2. The local surgeons aren’t nearly as familiar with ultrasound as they are with scans, consequently their comfort level is far less.
3. As you know ultrasound is often inconclusive, good chance it would have been for the second patient, she would have ended up getting the scan anyways, the ramifications of adding hours to an individual patient’s disposition have consequences for the entire department.
I like the idea of a non-iodine, non-radiation test for appendicitis as much as the next guy, but have found it not-quite-ready-for-primetime at my small community hospital. I use it for pregnant patients that I’m concerned have an appy, otherwise they usually end up in the scanner where operator dependence is not an issue.
January 14, 2009 at 1:53 pm
Scalpel — Nope, just like you said there’s no disincentive for anyone. You can’t win with the monday morning quarterbacks, you either overtest or undertest, the only solution is to not care what they think. People, the result of a test does not equate to its justification.
January 14, 2009 at 3:29 pm
Exactly.
January 14, 2009 at 5:44 pm
I would like to think that ED docs tend to be conscientious about CT scan use. For example, in trauma patients, I image based on findings. AMS, pain, deformity. However, when something is broken, bleeding or bashed to hell, the surgeons invariably come down and wonder why I haven’t “panscanned” portions of the patient that aren’t even injured!
So far, I can only think of two cases where the patient went straight to the OR without a CT scan for appendicitis. One had a rigid abdomen, fever, and a white count, while the other just kept vomiting up her contrast.
January 15, 2009 at 8:23 am
We send patients straight to the OR at least once or twice a week. If they are sick and have a rigid abdomen, there is no better imaging than direct visualisation without any further delays!
January 16, 2009 at 1:59 am
Now, one of these days someone has to invent the tricorder (like in star trek) so we can scan everyone without raditation side effects.
March 3, 2009 at 4:44 pm
And when some random arrogant internist suggests that other non-emergency doctors should get together to teach us how to do our jobs, I shake my head and smile and wish I could watch them flail about trying to do my job, just as I would if I tried to do theirs.
It amazes me that people, who work in all areas of medicine, find this so hard to understand.
People, the result of a test does not equate to its justification.
I could just repeat the comment above, but this is important enough to be a pass/fail test all by itself.